Tiago Proença dos Santos – The Paediatric Neurologist

We are at the Paediatric Emergency Room, where Tiago Proença dos Santos was called in to evaluate a case in the Paediatric Intensive Care Unit. The Santa Maria Hospital receives many children with intensive care support needs. As Santa Maria has the only paediatric Neurotrauma centre in southern Portugal (from Algarve to Coimbra), it receives many seriously ill patients with neurological complications.

Currently, Paediatrics provides medical care from birth to eighteen years of age. Santa Maria and other Portuguese hospitals realised that, within such a diversity of ages, there was the need to provide differentiated care, developing the different knowledge of the subspecialties that complement a generalist area like Paediatrics.

Tiago Proença dos Santos is a Paediatrician subspecialised in Neurology. After being trained as a Paediatrician for five years, he studied Paediatric Neurology for two more years. He graduated at the Faculty of Medicine of the University of Lisbon and, at that point, he realised he had to leave to broaden his horizons. It was at the Egas Moniz Hospital that he completed what was still called a general internship at the time and, despite the “gratifying experience” provided by that change, his ties to the Faculty remained strong, as he started working as an Assistant Professor of Medical Biochemistry (taught in the 1st and 2nd years) when he was in the fifth year of his studies.

Once he completed the general internship, Tiago Santos returned to Santa Maria to specialise in Paediatrics. And he never left.

He started giving Biochemistry lessons in 2003 and, later on, he also started teaching Paediatrics.

He says that, initially, Paediatrics was not an “absolute truth or the obvious choice”, because his primary interest were Neurosciences. Divided between Neurology and Psychiatry, and after delving deeper into those matters, he realised that he was still in the early stages of his education and he shouldn’t “narrow down his path”, so choosing a more comprehensive especially like Paediatrics seemed to make more sense. Today, as the good Paediatrician he is, he knows that one of the key aspects that led him to make up his mind was the fact that paediatric patients are permanently monitored, “what I like here is the monitoring philosophy itself. In other generalist areas, patients are referred to other specialties, often losing with the physician who made the referral. On the other hand, in Paediatrics there is always an interaction, as it is “strongly connected to the various complementary specialties”. But there is another advantage to choosing this general area – Tiago Proença’s target patients (children and adolescents) never turn up alone, they are supported by their parents, or other relatives, who, in general, ensure that the treatments are properly and swiftly administered. “My patients rarely miss an appointment. Their parents come, they are committed, sometimes too committed, putting pressure on us to have quick answers to all their doubts and insecurities”.

When we think about Neurology, maybe by default, we think it is more focused on older people, and that is a mistake. What exactly is Neuropaediatrics?

Tiago Santos: Neuropaediatrics is substantially different from adult Neurology. While an adult Neurologist sees patients with an established pattern of functions, where defects occur, in Neuropaediatrics we have patients who come to us with a complaint, for example, that they stopped walking or their head hurts, but we must also take into account that there are a number of functions that a baby is yet to acquire and will acquire in the coming years. For example, instead of a child that stopped talking, we might be dealing with a child that didn’t start talking when it should have, so what we are going to assess are all the functions that depend on the central and peripheral nervous system and play a role in differentiation when it comes to child development. In this case, we need to understand the risk factors and the factors that protect normal development. To give you an example, an eight-month old baby should be able to hold its head up, at six or eight months it needs to be able to sit, between twelve and eighteen months it needs to start walking, and all these steps need to be monitored. Any change may lead us to detect possible neurological diseases or disorders at an early stage. There is another very enticing thing in Neuropaediatrics, compared to adult Neurology, which is that a child’s brain is not yet fully formed, once a baby is born there will be an explosion of synapses (nerve endings that establish connections between neurons) and growth of functions in their central nervous system. This means that if a child has a stroke, or another illness, the potential for recovery is much greater. As the child is in a neurodevelopmental stage, as long as the diagnosis for intervention is made at an early stage, it will be possible for the injured areas to relocate and for their functions to be enhanced, making their recovery much more impressive than in the case of adults. On the other hand, there are obviously devastating and deadly diseases and conditions, but the physician is not only focused on treating and curing patients, but also on reaching a diagnosis, so people can understand what is happening to them, and on managing, with as much quality of life as possible, the path of the child and its family when faced with a serious illness.

Could you be dealing with a child whose profile suggests a neurological problem, due to a lack of developments in the central nervous system, and realise that there were simply no stimuli?

Tiago Santos: Yes. I would say that the nervous system lives in a permanent dialectic between biological and psychosocial factors. And, therefore, the cause of the pathology can lie on either side. When there is a delay, we always try to find out whether there was a correct stimulus, whether the child is in day care, whether there is a nanny or a grandmother who has many responsibilities other than focusing on the child. Then we try to increase the stimulus and intensify it. The nervous system does not work without stimulation, and stimulation does not work without the nervous system. And we are still far from understanding all the mechanisms that make everything work so well. But over the last two decades there have been very major developments and, for some of the diseases that were deemed incurable when I was studying at the Faculty, there are now therapies and the results allow us to dream of a cure in the future.

That is an eternal challenge for physicians isn’t it? To keep developing knowledge?

Tiago Santos: Yes, and this is one of the areas that require constant updating. In Neuropaediatrics it is particularly necessary to make this effort, because many of the pathologies we deal with are rare and we need to be trained to diagnose them. We only diagnose what we are looking for, and we only search for things we know exist.

How do you react to the stereotype that says that a woman will be a better Paediatrician because she “carried” a child and is therefore more sensitive to children?

Tiago Santos: I say that male Paediatricians can have children too. And I have three daughters. Yes, I’ve already dealt with that stereotype, but I’ve also dealt with the opposite, with families that preferred a male Paediatrician, because they preferred a different approach. Prejudice goes both ways. But, in general, I do think that the male and the female perspectives are shaped by different sensitivities, and I don’t know if that’s good or bad. Ultimately, we thrive on a wealth of different sensitivities, and it makes a lot more sense to have a mixed team that shares different points of view on the child’s experience. There are specialties, particularly in the surgical area, which used to be dominated by men and are now relying on an increasing number of women and benefiting from that added sensitivity.

As a father of three daughters, do you look at them from a paediatrician’s point of view?

Tiago Santos: I have no trouble keeping things separate, I’m more “negligent”, not as concerned, I’m more able to put things into perspective. I actually think that I watch them less than if I were not a paediatrician. But that is also because, fortunately, none of them has had a serious condition. That’s the other good news when it comes to Paediatrics – most children recover very fast from their illnesses, without sequelae.